Provider Demographics
NPI:1467472555
Name:BURGESS, MICHAEL W (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:W
Last Name:BURGESS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 67000
Mailing Address - Street 2:DEPT 272801
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-2728
Mailing Address - Country:US
Mailing Address - Phone:517-841-7490
Mailing Address - Fax:517-841-6917
Practice Address - Street 1:1401 W NORTH ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-3135
Practice Address - Country:US
Practice Address - Phone:517-782-2555
Practice Address - Fax:517-782-3399
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMB009713207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0120037OtherPHYSICIAN HEALTH PLAN
MI2764426Medicaid
MI0803800302OtherBCBSM
MI0803800302OtherBCBSM
0C86052002Medicare ID - Type Unspecified